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1/4166 2000 American College of PhysiciansAmerican Society of Internal Medicine

ORIGINAL ARTICLE

ELLEN WIEBE, MD

University of British Columbia

Vancouver, British Columbia

Canada

Eff Clin Pract. 2000;4:166-169.

Edited by John D. Birkmeyer,

MD

See related editorial on

pages 188-190.

This paper is available at ecp.acponline.org.

A Randomized Trial of

Aromatherapy To Reduce

Anxiety before Abortion

CONTEXT. Interest in the use of alternative therapies to reduce anxiety in patientsundergoing medical interventions is increasing. We sought to assess the effectivenessof aromatherapy involving essential oils in reducing preoperative anxiety in womenundergoing abortions.

SETTING. An urban, free-standing abortion clinic in Vancouver, BC.

PATIENTS. 66 women waiting for surgical abortions.

DESIGN. A double blind, randomized trial.

INTERVENTION. Ten minutes spent sniffing a numbered container with either a mix-ture of the essential oils vetivert, bergamot, and geranium (treatment arm) or a hairconditioner (placebo).

OUTCOME MEASURES. Anxiety was measured before and after the intervention byusing a verbal anxiety scale from 0 to 10.

RESULTS. The anxiety score was reduced by 1.0 point (5.0 to 4.0) in the aromatherapygroup and by 1.1 points (6.1 to 5.0) in the placebo group (P =0.71). The 95% CI on the0.1 greater decrease in anxiety for the placebo group extends from 0.55 less (favorsaromatherapy) to 0.75 greater (favors placebo).

CONCLUSION. Aromatherapy involving essential oils is no more effective than havingpatients sniff other pleasant odors in reducing preprocedure anxiety.

Although physicians have traditionally relied on pharmacologic methods toreduce anxiety in patients undergoing medical procedures, interest in usingalternative therapies is growing.1, 2 Such alternative, or complementary,therapiesinclude relaxation audiotapes, self-hypnosis, music therapy, therapeutic touch andmassage, and reflexology. These techniques have been used in attempts to reduceanxiety and to improve outcomes in patients undergoing procedures ranging fromcardiac surgery to dental and other ambulatory surgical procedures.36 Althoughthere are relatively few careful trials of such interventions, alternative therapies maymake medical procedures more tolerable to patients and reduce the need for post-

operative pain medications.7

One increasingly popular type of alternative therapy is aromatherapy. Witharomatherapy, patients sniff essential oils for various therapeutic effects, includinganxiety reduction. Numerous essential oils are used in aromatherapy, including euca-lyptus, geranium, lavender, orange, and rosewood. However, although aromather-apy is pleasant, inexpensive, and has no side effects (except for rare allergies), there isno evidence that it is effective in patients undergoing medical interventions. For thisreason, we performed a randomized clinical trial to assess whether aromatherapy ismore effective than placebo in reducing preoperative anxiety in women undergoingabortions.

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Methods

We performed a double-blind, placebo-controlled, ran-domized trial at an urban free-standing abortion clinic.Patients were recruited from women waiting for surgicalabortions. The only exclusions were allergies to perfumesor an inability to understand the consent form. No onewithdrew from the study after signing the consent form.

To ensure that patients had no memory associationswith the aroma and that they were blinded, we selectedunfamiliar substances for the treatment and placebogroups. Patients in the treatment arm sniffed a mixtureof essential oils recommended by an aromatherapist fortheir relaxation properties. The mixture consisted ofthree drops of vetivert, six drops of bergamot, and fourdrops of geranium in cold-pressed soya oil. These oilswere inexpensive, costing $11.99, $12.99 and $14.99(Can), respectively, for 10 mL each, and only a few dropswere used for each session. Although it is an essential oil

reported to cause relaxation, lavender was not usedbecause many people recognize its scent. For the placeboarm, we used a hair conditioner containing Brazil nut oil,a substance with an odor similar to that of the treatmentbut that contains no essential oils. We did not use wateror another odorless compound because patients would beaware that they had received the placebo.

After the routine counseling session but beforelorazepam was administered (given to all patients 30 to60 minutes before the procedure), women were asked tosniff a numbered container for 10 minutes. These con-tainers were opaque bottles that had been randomized

according to a table of random numbers and were num-bered sequentially by someone not involved in gainingconsent or collecting the data. The counselors andpatients were blinded to the treatment.

Our outcome measure was preoperative anxiety,scored on a linear scale. Before and after the intervention,the counselors asked the women, On a scale of 0 to 10,where 0 is no anxiety and 10 is the most anxious you haveever been, how anxious are you feeling right now?Thesample size was calculated to give an 80% power of

detecting a 1-unit difference in the change in anxietyscores between the treatment groups. The alpha levelwas two-tailed 0.05. The data were entered into SPSSstatistical software (SPSS, Inc., Chicago, Illinois) andanalyzed by using two-sample t-tests and MannWhitney tests.

Results

There were 36 participants in the aromatherapy groupand 30 in the placebo group. As shown in Table 1, thesegroups were similar with respect to age and number ofprevious births and abortions. Patients in the aroma-therapy group had a slightly lower gestational age thanthose in the placebo group (58 vs. 63 days, P =0.04).There was a trend toward lower baseline (before thestudy intervention) anxiety in the aromatherapy group(5.0 vs. 6.1 in the placebo group, P =0.07), but this dif-ference was not statistically significant.

Figure 1 shows that, with administration of thestudy intervention, anxiety scores decreased significantlyin both the aromatherapy group (from 5.0 to 4.0,P < 0.01)and the placebo group (from 6.1 to 5.0, P < 0.01).However, the net decrease in preoperative anxiety scoresdid not differ between the two groups (1.0 vs. 1.1, P =0.71). As shown in Figure 2, the 95% CI on the 0.1 greaterdecrease in anxiety for the placebo group extends from0.55 less (favors aromatherapy) to 0.75 greater (favorsplacebo).

Discussion

This is the first reported randomized clinical trial thatassesses the value of aromatherapy in reducing anxietyin patients undergoing a medical procedure. Althoughanxiety scores fell after aromatherapy involving essentialoils, the decrease was similar to that in patients receivingthe placebo (hair conditioner). Thus, there was no evi-dence that aromatherapy is more effective in reducingpreprocedure anxiety than having patients sniff otherpleasant scents. Anxiety scores may have diminished in

TABLE 1

Baseline Characteristics

CHARACTERISTIC

Maternal age,yr

Gestational age,d

Previous births

Previous abortions

PLACEBO

(n=30)

26.1

63.4

0.5

0.6

AROMATHERAPY

(n=36)

26.9

58.0

0.7

0.7

P VALUE

>0.2

0.04

>0.2

>0.2

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Effective Clinical Practice July/August 2000 Volume 3 Number 4 169

who would then be unblinded. Conversely, by using afragrant substance for the control group (we used hairconditioner), it is possible that the study outcome wasinfluenced by our choice of placebo. Finally, our studyrelied on a single anxiety measure, assessed on a scale of0 to 10. We employed this scale because it is simple to use;easy to understand; and unlike other anxiety measures,useful for identifying changes in anxiety from one pointin time to another. Although similar scales for measuringpain are well validated,12 their use for quantifying anxi-ety is less well described.

Like music, art, or beautiful scenery, pleasantodors may be relaxing for many patients. Becausearomatherapy is relatively inexpensive and essentiallyrisk free, there is no reason to discourage its use in med-ical practice. However, there remains no evidence thatessential oils are crucial to the value of aromatherapy.

References

1. Oz MC, Whitworth GC, Liu EH. Complementary medicinein the surgical wards. JAMA. 1998;279:170-1.

2. Organ CH Jr. Alternative medicine and surgery [Editorial].1998;133:1153-4.

3. Enqvist B, Fischer K. Pre-operative hypnotic techniquesreduce consumption of analgesics after surgical removal ofthird mandibular molars: a brief communication. Int J ClinExp Hypn. 1997;45:102-8.

4. Domar AD, Noe JM, Benson H. The preoperative use ofrelaxation response with ambulatory surgery patients. JHuman Stress. 1987;13:101-7.

5. Nelson NJ. Scents or nonsense: aromatherapys benefits stillsubject to debate. J Natl Cancer Inst. 1997;89:1334.

6. Augustin P, Hains AA. Effect of music on ambulatory surgerypatientspreoperative anxiety. AORN J. 1996;63:750,753-8.

7. Ashton C Jr, Whitworth GC, Seldomridge JA, et al. Self-hyp-nosis reduces anxiety following coronary bypass surgery. Aprospective, randomized trial. J Cardiovasc Surg (Torino).1997;38:69-75.

8. Roberts A, Williams JMG. The effect of olfactory stimulationon fluency, vividness of imagery and associated mood: a pre-liminary study. Brit J Med Psychol. 1992;65:197-9.

9. Romine IJ, Bush AM, Geist CR. Lavender aromatherapy inrecovery from exercise. Percept Mot Skills. 1999;88:756-8.

10. Brownfield A. Aromatherapy in arthritis: a study. Nurs Stand.1998;13:34-5.

11. Brooker DJR, Snape M, Johnson E, Ward D, Payne M. Singlecase evaluation of the effects of aromatherapy and massage ondisturbed behavior in severe dementia. Br J Clin Psychol.1997;36:287-96.

12. Jensen MP, Miller L Fisher LD. Assessment of pain duringmedical procedures. a comparison of three scales. Clin J Pain.1998;14:343-9.

Acknowledgments

The author thanks Patricia Hoolihan, co-owner of AromaBorealis, for providing the aromatherapy expertise and supplies;the staff of Everywomans Health Centre, especially the coun-

selors, for ensuring that the study was completed; MeeraSelvacone, medical student research assistant, for helping withdata collection and entry; the Tzu Chi Institute forComplementary and Alternative Medicine; and Dr. JonathanBerkowitz for providing statistical support.

Correspondence

Ellen Wiebe, MD, 1013-750 West Broadway, Vancouver BCV5Z 1H9, Canada; telephone: 604-873-8303; fax: 604-873-8304;e-mail: ewiebe@interchange.ubc.ca.

Aromatherapy involving essential oils is increasing in

popularity; however, its therapeutic value has not been

carefully assessed.

We performed a double-blind, placebo-controlled trial

to determine the effectiveness of aromatherapy for

reducing anxiety in women awaiting surgical abortions.

Aromatherapy and sniffing a placebo were equally

effectiveeach reduced anxiety scores by about

1 point (on a scale from 0 to 10).

Although there is no reason to discourage the use of

aromatherapy, essential oils are no more effective than

other pleasant-smelling substances.

Take-Home Points